Orthopaedic Trauma Surgery Research Articles

Microstructure and Corrosion Behaviour of Mg-Ca and Mg-Zn-Ag Alloys for Biodegradable Hard Tissue Implants

Trauma orthopaedic surgery was the first domain to use degradable metallic implants made of magnesium alloys since the early 20th century. Unfortunately, the major limitation that consists of rapid degradation and subsequent implant failure, which occur in physiological environments with a pH between 7.4 and 7.6, prevents its widespread application. The biggest challenge in corrosion assay is the choice of the testing medium in order to reproduce more closely in vivo conditions. The current study was focused on two Mg-Zn-Ag alloys (Mg7Zn1Ag and Mg6Zn3Ag) and the Mg1Ca alloy. Dulbecco’s Modified Eagle Medium (DMEM) and Kokubo’s simulated body fluid solution (SBF) were selected as testing mediums and we follow the corrosion evaluation by the corrosion rate and mass loss. Also, the corrosion behaviour was interpreted in correlation with the microstructural features and alloying elements of the experimental magnesium-based alloys revealed by optical microscopy (OM), X-ray diffraction (XRD), and scanning electron microscopy (SEM) coupled with energy dispersive spectroscopy (EDX). The experimental results highlight the more corrosive nature of the SBF environment and that a higher percentage of silver (2.5 wt.%) exhibited a better corrosion resistance. We consider that the magnesium alloy Mg6Zn3Ag showed valuable biodegradation characteristics to be considered as raw materials for manufacturing small trauma implants.

Orthopaedic trauma surgery versus fracture care: what’s the difference?

Orthopaedic trauma surgery versus fracture care: what’s the difference?

Characteristics of emergency general surgery services in Switzerland: a nationwide survey

ObjectiveRunning an emergency general surgery (EGS) service is challenging and requires significant personnel and institutional resources. The aim of this study was to achieve a nationwide overview of the individual EGS service organizations in public hospitals in Switzerland.MethodsAll Swiss public hospitals with a surgical and emergency department were included and contacted by telephone. General surgeons were interviewed between December 2021 and January 2022 using a standardized questionnaire.ResultsSeventy-two out of 79 public hospitals in Switzerland (91.1%) agreed to the survey. They employed 1,581 surgeons in 19 (26.4%) hospitals with < 100 beds, 39 (54.2%) hospitals with 100–300 beds, 7 (9.7%) with 300–600 beds, and 7 (9.7%) with > 600 beds. The median number of surgeons per hospital was 20.5 (IQR 13.0–29.0). Higher level of care (intermediate or intensive care unit) was significantly less available in small hospitals (< 100 beds). The median hour of designated emergency operating room capacity per day was 14 h (IQR 14–24) for all hospitals with < 600 beds and 24 h (IQR 14–24) for the largest hospitals (> 600 beds). With increasing hospital size, there was a significant increase in the number of surgical units where EGS and orthopedic trauma surgery were covered by two separate teams (21.1% vs. 43.6% vs. 85.7% vs. 100%, p = 0.035). The median number of surgeons on-call per hospital and per 24 h was 5.0 (IQR 3.3–6.0).ConclusionLack of higher level of care in small hospitals, limited emergency OR capacity and short rotations of on-call teams are major drawbacks of many current EGS systems in Switzerland. Centralization of critically ill EGS patients and reorganization of surgical on-call systems to designated acute care surgery teams should be considered.

Spinolaminar locking plates improve fixation strength compared to pedicle screws: a biomechanical analysis.

Pedicle screw loosening is a significant complication of posterior spinal fixation, particularly among osteoporotic patients and in deformity constructs. In orthopedic trauma surgery, locking plates and screws have revolutionized the fixation of osteoporotic fractures. We have combined the traumatology principle of fixed-angle locking plate fixation with the spine principles of segmental instrumentation. A novel spinolaminar locking plate was designed based on morphometric studies of human thoracolumbar vertebrae. The plates were fixed to cadaveric human lumbar spines and connected to form 1-level L1-L2 or L4-L5 constructs and compared to similar pedicle screw constructs. Pure moment testing was performed to assess range of motion before and after 30,000 cycles of cyclic fatigue. Post-fatigue fixture pullout strength was assessed by applying a continuous axial tensile force oriented to the principal axis of the pedicle until pullout was observed. Spinolaminar plate fixation resulted in superior pullout strength compared to pedicle screws (1,065 ± 400N vs. 714 ± 284N, p = 0.028). Spinolaminar plates performed equivalently to pedicle screws in range of motion reduction during flexion/extension and axial rotation. Pedicle screws outperformed the spinolaminar plates in lateral bending. Finally, no spinolaminar constructs failed during cyclic fatigue testing, whereas one pedicle screw construct did. The spinolaminar locking plate maintained adequate fixation post-fatigue, particularly in flexion/extension and axial rotation compared to pedicle screws. Moreover, spinolaminar plates were superior to pedicle screw fixation with respect to cyclic fatiguing and pullout strength. The spinolaminar plates offer a viable option for posterior lumbar instrumentation in the adult spine.

Efficacy of different doses of dexmedetomidine as an adjuvant to bupivacaine in sub-arachnoid block for patients undergoing lower limb surgeries

Objective: To determine the difference in efficacy of bupivacaine as adjuvant to 5 µg&amp; 10 µg of dexmedetomidine respectively during intrathecal administration in prolongation of duration of sensory block (as a main primary variable) in lower limb orthopedic surgery. Setting: Department of anesthesia, MTI-HMC, Peshawar. Study design: Randomized controlled trails. Duration of study: From 1st Feb 2021 to 30th July 2021. Subjects &amp; Methods: Each patient enrolled in study after proper consent in written form and counselling was subjected to complete medical history, clinical examination. Spinal column was the primary focus of examination. All standard vitals monitoring equipment attahed. Baseline readings obtained and noted. Double i/v line was secured. Patients were preloaded with 10ml/ kg of Ringer Lactate. Spinal injection of anesthetic. Conclusion: Results obtained from this study showed that adding 10 micro gram of dexmeditomidine in comparison to 5 micro gram to spinal anesthetic for lower limb traumatic orthopedic surgery significantly prolongs the sensory block, analgesia, decreased onset time for block, early rehabilitaion and ambulation of patients which has various socioecnomic advantages.

An overview of bone cement: Perioperative considerations, complications, outcomes and future implications.

Polymethyl methacrylate is commonly known as bone cement and is widely used for implant fixation in various orthopaedic arthroplasty and trauma surgery. The first bone cement use in orthopaedics is widely accredited to the famous English surgeon, John Charnley, who in 1958, used it for total hip arthroplasty. Since then, there have been many developments in cementing techniques in arthroplasty surgery. This overview aims to cover the perioperative considerations of bone cement, including cementing techniques, current outcomes and complications such as bone cement implantation syndrome. The overview will additionally consider future developments involving bone cement in orthopaedic arthroplasty.

Simple design and analysis strategies for solving problems in observational orthopaedic clinical research.

Randomized controlled trials are the gold standard to establishing causal relationships in clinical research. However, these studies are expensive and time consuming to conduct. This article aims to provide orthopaedic surgeons and clinical researchers with methodology to optimize inference and minimize bias in observational studies that are often much more feasible to undertake. To mitigate the risk of bias arising from their nonexperimental design, researchers must first understand the ways in which measured covariates can influence treatment, outcomes, and missingness of follow-up data. With knowledge of these relationships, researchers can then build causal diagrams to best understand how to control sources of bias. Some common techniques for controlling for bias include matching, regression, stratification, and propensity score analysis. Selection bias may result from loss to follow-up and missing data. Strategies such as multiple imputation and time-to-event analysis can be useful for handling missingness. For longitudinal data, repeated measures allow observational studies to best summarize the impact of the intervention over time. Clinical researchers familiar with fundamental concepts of causal inference and techniques reviewed in this article will have the power to improve the quality of inferences made from clinical research in orthopaedic trauma surgery.

Surgeon Estimated Blood Loss is Discordant with Calculated Blood Loss in Acetabular and Pelvic Fracture Surgery.

To compare blood loss as estimated by surgeon estimated blood loss (EBL), the Gross formula, and the HB equation in open pelvic and acetabular surgery. Retrospective cohort study. Single Level I academic trauma center. We included 710 patients 18-89 years of age who underwent acetabular or pelvic surgery for management of fracture between 2008 and 2018. Surgical treatment for management of acetabular or pelvic fracture and blood transfusion when deemed clinically appropriate in the perioperative setting. Surgeon EBL, calculated blood loss (using the Gross formula, a Gross formula derivative, and the HB equation with both Moore and Nadler blood volume estimations). 192 patients (27%) received intraoperative blood transfusions. Surgeon EBL significantly differed from all formulas except the Gross/ Nadler and the modified Gross/ Nadler calculations. Gross and HB calculation methods yielded similar results in the overall cohort, but yielded significantly different results in the subgroup analysis. Use of a corrective transfusion factor mildly improved correlation of the Gross equation with EBL. At high levels of blood loss, surgeon EBL predictions became more discordant with calculated blood loss values. When assessing only patients who did not receive transfusions, concordance improved. Blood loss in pelvic and acetabular surgery is challenging to quantify, and this study demonstrates discordance between formula predictions and surgeon estimated blood loss. At higher levels of blood loss, this discrepancy worsens. This exploratory study highlights the need for the development of improved methods of quantifying blood loss in orthopaedic trauma surgery. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of promoting the concept of rapid rehabilitation surgery on perioperative pain management in patients undergoing orthopedic trauma surgery.

Effect of promoting the concept of rapid rehabilitation surgery on perioperative pain management in patients undergoing orthopedic trauma surgery.

Endocrine and metabolic monitoring for anesthesia care in orthopedic trauma surgery on the lower extremities of children: prospective comparative study

BACKGROUND: Standard anesthesia monitoring during surgery only indirectly allows us to estimate achieving an effective level of analgesia sufficient to protect the patient from surgical trauma. Recently, studies have analyzed cortisol, glucose, and lactate levels during surgery in children and adults; however, data presented remain inconsistent.&#x0D; OBJECTIVE: This study aimed to conduct a prospective comparative analysis of endocrine metabolic dynamic rates in orthopedic trauma surgery on the lower extremities of children.&#x0D; MATERIALS AND METHODS: The study included 39 children who underwent orthopedic trauma surgery. They were divided into two groups: group 1 (n=17) underwent multicomponent balanced general anesthesia, and group 2 (n=22) received combined anesthesia (multicomponent balanced general anesthesia combined with regional blockade of the sciatic and femoral nerves). The dynamics of cortisol, glucose, and lactate indicators at three stages of the perioperative period, total amount of fentanyl, and need for an inhalation anesthetic were examined.&#x0D; RESULTS: Indicators of cortisol, glucose, and lactate in mixed venous blood during surgery did not exceed the age norm in both groups. In group 1, cortisol, glucose, and lactate levels did not statistically differ at all stages of the study. In group 2, cortisol and lactate levels increased at the fifth stage (traumatic stage) of surgery, and lactate levels increased in the sixth stage (end of surgery). In intergroup comparison, the lactate level at the traumatic stage of surgery was higher in group 1 than in group 2 (p=0.048). Cortisol and glucose levels at the stages of the study did not differ significantly. The total amount of fentanyl for pain relief in group 1 was 4.1 [3.3; 5.0] g/kg, which was 8.2 times higher than that in group 2, with 0.5 [0.4; 0.53] g/kg (p 0.0001).&#x0D; CONCLUSION: Both anesthesia methods ensure stable levels of cortisol, glucose, and lactate, and adequate level of analgesia at all stages of surgery; however, the use of a conduction blockade as a component of combined anesthesia provides more pronounced antinociceptive protection and reduces surgical stress in children.

An Overview of 3D Anatomical Model Printing in Orthopedic Trauma Surgery.

3D object printing technology is a resource increasingly used in medicine in recent years, mainly incorporated in surgical areas like orthopedics. The models made by 3D printing technology provide surgeons with an accurate analysis of complex anatomical structures, allowing the planning, training, and surgery simulation. In orthopedic surgery, this technique is especially applied in oncological surgeries, bone, and joint reconstructions, and orthopedic trauma surgeries. In these cases, it is possible to prototype anatomical models for surgical planning, simulating, and training, besides printing of instruments and implants. The purpose of this paper is to describe the acquisition and processing from computed tomography images for 3D printing, to describe modeling and the 3D printing process of the biomodels in real size. This paper highlights 3D printing with the applicability of the 3D biomodels in orthopedic surgeries and shows some examples of surgical planning in orthopedic trauma surgery. Four examples were selected to demonstrate the workflow and rationale throughout the process of planning and printing 3D models to be used in a variety of situations in orthopedic trauma surgeries. In all cases, the use of 3D modeling has impacted and improved the final treatment strategy. The use of the virtual anatomical model and the 3D printed anatomical model with the additive manufacturing technology proved to be effective and useful in planning and performing the surgical treatment of complex articular fractures, allowing surgical planning both virtual and with the 3D printed anatomical model, besides being useful during the surgical time as a navigation instrument.

Role of single-dose intravenous iron therapy for the treatment of anaemia after orthopaedic trauma: protocol for a pilot randomised controlled trial

IntroductionOrthopaedic trauma and fracture care commonly cause perioperative anaemia and associated functional iron deficiency due to a systemic inflammatory state. Modern, strict transfusion thresholds leave many patients anaemic; managing this...

EEG responses to standardised noxious stimulation during clinical anaesthesia: a pilot study.

During clinical anaesthesia, the administration of analgesics mostly relies on empirical knowledge and observation of the patient's reactions to noxious stimuli. Previous studies in healthy volunteers under controlled conditions revealed EEG activity in response to standardised nociceptive stimuli even at high doses of remifentanil and propofol. This pilot study aims to investigate the feasibility of using these standardised nociceptive stimuli in routine clinical practice. We studied 17 patients undergoing orthopaedic trauma surgery under general anaesthesia. We evaluated if the EEG could track standardised noxious phase-locked electrical stimulation and tetanic stimulation, a time-locked surrogate for incisional pain, before, during, and after the induction of general anaesthesia. Subsequently, we analysed the effect of tetanic stimulation on the surgical pleth index as a peripheral, vegetative, nociceptive marker. We found that the phase-locked evoked potentials after noxious electrical stimulation vanished after the administration of propofol, but not at low concentrations of remifentanil. After noxious tetanic stimulation under general anaesthesia, there were no consistent spectral changes in the EEG, but the vegetative response in the surgical pleth index was statistically significant (Hedges' g effect size 0.32 [95% confidence interval 0.12-0.77], P=0.035). Our standardised nociceptive stimuli are not optimised for obtaining consistent EEG responses in patients during clinical anaesthesia. To validate and sufficiently reproduce EEG-based standardised stimulation as a marker for nociception in clinical anaesthesia, other pain models or stimulation settings might be required to transfer preclinical studies into clinical practice. DRKS00017829.

Biodegradable and Cytocompatible Hydrogel Coating with Antibacterial Activity for the Prevention of Implant-Associated Infection.

Implant-associated infection (IAI) caused by pathogens colonizing on the implant surface is a serious issue in the trauma-orthopedic surgery, which often leads to implant failure. The complications of IAI bring a big threat to the clinical practice of implants, accompanied by significant economic cost and long hospitalization time. In this study, we propose an antibiotics-free strategy to address IAI-related challenges by using a biodegradable and cytocompatible hydrogel coating. To achieve this, a novel hydrogel system was developed to combine the synergistic effects of good cell affinity and antibacterial properties. The hydrogel material was prepared by modifying a photocross-linkable gelatin-based polymer (GelMA) with cationic quaternary ammonium salt (QAS) groups via a mild and simple synthesis procedure. By engineering the length of the hydrophobic carbon chain on the QAS group and the degree of functionalization, the resulting GelMA-octylQAS hydrogel exhibited an integration of good mechanical properties, biodegradability, excellent bactericidal activity against various types of bacteria, and high cytocompatibility with mammalian cells. When coated onto the implant via the in situ cross-linking procedure, our hydrogel demonstrated superior antimicrobial ability in the infective model of femoral fracture of rats. Our results suggest that the GelMA-octylQAS hydrogel might provide a promising platform for preventing and treating IAI.

Effect of transauricular nerve stimulation on perioperative pain: a single-blind, analyser-masked, randomised controlled trial

BackgroundActivation of central autonomic pathways, including those regulating the arterial baroreflex, might reduce acute pain. We tested the hypothesis that transcutaneous auricular nerve stimulation (TAN) reduces pain after orthopaedic trauma surgery through autonomic modulation. MethodsA total of 86 participants aged >18 yr were randomly assigned to 50 min of either sham or active bilateral TAN, undertaken before, and again 24 h after, surgery for orthopaedic trauma. The primary outcome was absolute change in pain 24 h postoperatively, comparing the 100 mm visual analogue scale (VAS) before and after TAN. Secondary outcomes included the minimal clinically important difference in pain (>10 mm increase or reduction in VAS) before/after surgery, using intention-to-treat analysis. Holter monitoring, the analysis of which was masked to allocation, quantified autonomic modulation of heart rate. ResultsFrom June 22, 2021 to July 7, 2022, 79/86 participants (49 yr; 45% female) completed TAN before and after surgery. For the primary outcome, the mean reduction in VAS was 19 mm (95% confidence interval [CI]: 12–26) after active TAN (n=40), vs 10 mm (95% CI: 3–17) after sham TAN (n=39; P=0.023). A minimally clinically important reduction in postoperative pain occurred in 31/40 (78%) participants after active TAN, compared with 15/39 (38%) allocated to sham TAN (odds ratio 5.51 [95% CI: 2.06–14.73]; P=0.001). Only active TAN increased heart rate variability (log low-frequency power increased by 0.19 ms2 [0.01–0.37 ms2]). Prespecified adverse events (auricular skin irritation) occurred in six participants receiving active TAN, compared with two receiving sham TAN. ConclusionBilateral TAN reduces perioperative pain through autonomic modulation. These proof-of-concept data support a non-pharmacological, generalisable approach to improve perioperative analgesia.

Investigation of litigation in trauma orthopaedic surgery.

It has been said that the number of orthopaedic claims has increased in the last few years. Investigation through the most prevalent cause would help to prevent further cases. To review the cases of medical complaints in orthopedic patients who had been involved in a traumatic accident. A retrospective multi-center review of trauma orthopaedic-related malpractice lawsuits from 2010 to 2021 was conducted utilizing the regional medicolegal database. Defendant and plaintiff characteristics along with fracture location, allegations, and litigation outcomes were investigated. A total of 228 claims referred to trauma-related conditions with a mean age of 31.29 ± 12.56 were enrolled. The most common injuries were at hand, thigh, elbow, and forearm, respectively. Likewise, the most common alleged complication was related to malunion or nonunion. In 47% of the cases, the main problem that led to the complaint was the inappropriate or insufficient explanation to the patient, and in 53%, there was a problem in the surgery. Eventually, 76% of the complaints resulted in a defense verdict, and 24% resulted in a plaintiff verdict. Surgical treatment of hand injuries and surgery in non-educational hospitals received the most complaints. The majority of litigation outcomes were caused by a physician's failure to fully explain and educate the traumatic orthopedic patients and technological errors.

Occurrence rates and risk factors of in-hospital venous thromboembolism, major bleeding, and death in patients receiving fondaparinux after orthopedic surgery or trauma surgery

AimFondaparinux is a synthetic anticoagulant that inhibits thrombosis by suppressing factor Xa. The efficacy of fondaparinux for orthopedic surgeries has been revealed by several foreign studies; however, relevant evidence in Chinese patients is lacking. This study intended to investigate the occurrence rate and risk factors of in-hospital venous thromboembolism (VTE), major bleeding, and death in patients receiving fondaparinux after orthopedic surgery or trauma surgery.MethodsTotally, 1258 patients who received fondaparinux after orthopedic surgery or trauma surgery were retrospectively enrolled. Meanwhile, in-hospital VTE, major bleeding, and death were obtained for assessment. Besides, adverse events were recorded.ResultsThe occurrence rates of in-hospital VTE, major bleeding, and death were 2.5%, 21.8%, and 0.0%, respectively. The multivariate logistic regression analysis revealed that only age (> 60 years vs. ≤ 60 years) (odd ratios (OR) = 3.380, P = 0.013) was independently correlated with increased risk of in-hospital VTE. Additionally, osteoarthritis diagnosis (OR = 3.826, P < 0.001), femoral head necrosis diagnosis (OR = 1.809, P = 0.034), hip replacement (vs. internal fracture fixation) (OR = 2.199, P = 0.007), knee replacement (vs. internal fracture fixation) (OR = 2.781, P = 0.002), and serum creatinine (abnormal vs. normal) (OR = 1.677, P = 0.012) were independently linked to a higher risk of in-hospital major bleeding. Moreover, the common adverse events included pain (56.6%), wound bleeding (23.0%), increased drainage (5.2%), etc.ConclusionFondaparinux realizes low occurrence rates of in-hospital VTE and major bleeding with tolerable adverse events in patients receiving orthopedic surgery or trauma surgery.

A randomized controlled trial of patient recall after detailed written consent versus standard verbal consent in adults with routine orthopaedic trauma.

Patient decision aids have previously demonstrated an improvement in the quality of the informed consent process. This study assessed the effectiveness of detailed written patient information, compared to standard verbal consent, in improving postoperative recall in adult orthopaedic trauma patients. This randomized controlled feasibility trial was conducted at two teaching hospitals within the South Eastern Sydney Local Health District. Adult patients (age ≥ 18 years) pending orthopaedic trauma surgery between March 2021 and September 2021 were recruited and randomized to detailed or standard methods of informed consent using a random sequence concealed in sealed, opaque envelopes. The detailed group received procedure-specific written information in addition to the standard verbal consent. The primary outcome was total recall, using a seven-point interview-administered recall questionnaire at 72 hours postoperatively. Points were awarded if the participant correctly recalled details of potential complications (maximum three points), implants used (maximum three points), and postoperative instructions (maximum one point). Secondary outcomes included the anxiety subscale of the Hospital and Anxiety Depression Scale (HADS-A) and visual analogue scale (VAS) for pain collected at 24 hours preoperatively and 72 hours postoperatively. Additionally, the Patient Satisfaction Questionnaire Short Form (PSQ-18) measured satisfaction at 72 hours postoperatively. A total of 60 patients were randomized, 32 to the standard group and 28 to the detailed group. Patients in the detailed group had significantly higher total recall score compared to the standard group (mean difference 1.29 points (95% confidence interval (CI) 0.51 to 2.08); p = 0.002). There were no differences in HADS-A (mean difference 0.39 (95% CI -2.11 to 2.88); p = 0.757), VAS pain (mean difference 5.71 (95% CI -22.25 to 11.11); p = 0.499), or PSQ-18 (mean difference 0.499; 95% CI -1.6 to 3.42; p = 0.392). Detailed written tools are useful in improving postoperative recall in adult orthopaedic trauma patients.

The Opioid Risk Tool Correlates With Increased Postsurgical Opioid Use Among Patients With Orthopedic Trauma.

The aim of this study was to determine whether the Opioid Risk Tool (ORT), which has been validated in patients with chronic pain, relates to postoperative opioid consumption. The purpose was to investigate a tool that could help identify patients with orthopedic trauma at high risk for opioid abuse. Patients 18 to 80 years old presenting between May 2018 and August 2018 to UNC Hospitals with isolated orthopedic injuries that required surgical intervention were considered for inclusion. At 2 weeks postoperatively, the ORT was administered. At 6 weeks postoperatively, total morphine milligram equivalents (MME) was determined for each patient. Each patient was also categorized as either low risk (LR) or moderate to high risk (M-HR) based on the cumulative ORT score. Finally, opioid prescriptions provided after 6 weeks postoperatively was recorded. One hundred four patients met the inclusion criteria, and 42 completed the questionnaire. Thirty patients were categorized as LR and 12 patients as M-HR. Patients who were at M-HR consumed a significantly higher MME than LR patients (LR=406 [95% CI, 287-526]; M-HR=824 [95% CI, 591-1057]; P=.001). Linear regression analysis showed that for each additional risk factor, opioid consumption increased by 61 MME, and approximately 58% of the variation in opioid consumption could be explained by the ORT (beta=61, R2=0.58, P=.02). In this study, the ORT predicted which patients would have increased opioid consumption after orthopedic trauma surgery. Each additional risk factor correlated with increased opioid use. The ORT did not predict which patients would continue to receive opioid prescriptions after 6 weeks postoperatively. [Orthopedics. 2023;46(4):e219-e222.].

Direct oral anticoagulants for venous thromboembolism prophylaxis in orthopaedic trauma: a clear first choice?

‘The brain may devise laws for the blood’ William Shakespeare, Merchant of Venice (1598)1 Prevention of venous thromboembolism (VTEp) is an integral part in the care of orthopaedic patients. VTE the leading cause of preventable mortality in hospital2 and orthopaedic surgery confers particularly high-risk.3 VTE currently complicates 2%–7% of all orthopaedic surgery.2 Symptomatic VTE results in reduced quality of life and causes mortality in 6%–12% of cases.4 VTE may increase length of stay (LOS) in hospital and confers large economic costs.5 Biological rationale supports the efficacy of direct oral anticoagulants (DOACs) for VTEp in orthopaedic surgery. Orthopaedic surgery accentuates all aspects of Virchow's Triad due to trauma-induced thromboplastin upregulation, intraoperative torniquet use, immobilization, bed rest and polymethylmethacrylate cement.6 DOACs prevent subsequent coagulation by inhibiting Factor Xa or II.6 Factor Xa inactivation is also the mechanism of action for low-molecular-weight heparins (LMWH) which are commonly used for VTEp after orthopaedic surgery.3 However, DOACs act directly on coagulation factors, unlike LMWH which is reliant on the presence of antithrombin III. DOACs do not require dose adjustment in obesity and avoid the gastrointestinal and renal side-effects of aspirin. The disadvantage of DOACs is that they are not all reversible and have a longer washout time than LMWH. DOACs have already demonstrated utility for VTEp in alternative domains. Most notably, DOACs are now suitable first-line options for VTEp after hip and knee arthroplasty. LMWHs such as enoxaparin, had historically been the gold-standard for VTEp after arthroplasty.7 However rivaroxaban and apixaban have demonstrated superior VTEp than LMWH in recent meta-analyses of randomized controlled trials (RCT).8, 9 Rivaroxaban was associated with a greater bleeding risk than LMWH.8, 9 This is important to note as, even minor bleeding is a concern to orthopaedic surgeons as it may increase risk of infection. However, apixaban has demonstrated a lesser bleeding risk than LMWH.8, 9 Meanwhile, aspirin has shown significantly increased VTE and mortality rates when compared to DOACs and LMWH.10, 11 Apixaban and rivaroxaban have also demonstrated reduced rates of symptomatic VTE than LMWH without increased incidences of major bleeding, when used for VTEp in oncology.12 Studies from the last decade have consistently demonstrated the benefits of DOACs over LMWH for VTEp in orthopaedic trauma surgery.13, 14 A recent systematic review and meta-analysis reported significantly reduced deep venous thrombosis rates when Factor Xa inhibiting DOACs were compared to LMWH for VTEp after lower limb fracture surgery.14 DOACs were also not inferior to LMWH for prevention of mortality, pulmonary embolism and bleeding, both major and minor. A RCT not included in the aforementioned study demonstrated reduced VTE risk with no increase bleeding risk, including minor bleeding, when rivaroxaban was compared to LMWH.13 Therefore the increased bleeding with rivaroxaban in some arthroplasty data is not reflected in orthopaedic trauma. Aspirin has not demonstrated effective VTEp after orthopaedic trauma surgery when compared to LMWH.15 The results of these studies have not yet effected an update to international guidelines for VTEp after orthopaedic trauma surgery (Table 1). DOACs also offer large economic savings, superior patient experience and improved adherence when compared to LMWH. In analyses for total hip replacement and total knee replacement, dabigatran, rivaroxaban and apixaban demonstrate saving of €152 and €116, €177 and €85, €223 and €135 per patient respectively.5 DOACs are administered orally compared to LMWH administration by subcutaneous injection. LMWH has subsequently been associated with high rates of non-adherence after hospital discharge.16 This is particularly concerning as the majority of VTE occurs following hospital discharge.17 Evidence suggests DOACs are the first choice over LMWH for VTEp after orthopaedic trauma surgery due to reduced rates of VTE, equivocal bleeding risk and mortality, reduced cost and improved patient experience. Where bleeding risk is high, apixaban may be used instead of rivaroxaban. Where risk of reoperation is high, DOACs should be avoided as they are not reversible. Open access publishing facilitated by The University of Adelaide, as part of the Wiley - The University of Adelaide agreement via the Council of Australian University Librarians. Bhuvanesh Ravichandran: Investigation; methodology; writing – review and editing. Brandon Stretton: Conceptualization; formal analysis; investigation; methodology; writing – review and editing. Joshua G. Kovoor: Conceptualization; formal analysis; investigation; methodology; writing – review and editing. Stephen Bacchi: Formal analysis; supervision; writing – review and editing. Joseph N. Hewitt: Investigation; resources; writing – review and editing. Christopher D. Ovenden: Formal analysis; investigation; supervision; writing – review and editing. Aashray K. Gupta: Conceptualization; investigation; resources; supervision; writing – review and editing. Ruurd L. Jaarsma: Conceptualization; supervision; validation; visualization; writing – review and editing. Guy J. Maddern: Conceptualization; supervision; validation; visualization; writing – review and editing. Ameya Bhanushali: Writing – review and editing.